Glossary of Health Coverage and Medical Terms

Glossary of Health Coverage and Medical Terms

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This glossary has many commonly used terms, but isn¡¯t a full list. These glossary terms and definitions are intended

to be educational and may be different from the terms and definitions in your plan. Some of these terms also

might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan

governs. (See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan

document.)

Bold blue text indicates a term defined in this Glossary.

See page 4 for an example showing how deductibles, co-insurance and out-of-pocket limits work together in a real

life situation.

Allowed Amount

Maximum amount on which payment is based for

covered health care services. This may be called ¡°eligible

expense,¡± ¡°payment allowance" or "negotiated rate." If

your provider charges more than the allowed amount, you

may have to pay the difference. (See Balance Billing.)

Appeal

A request for your health insurer or plan to review a

decision or a grievance again.

Balance Billing

When a provider bills you for the difference between the

provider¡¯s charge and the allowed amount. For example,

if the provider¡¯s charge is $100 and the allowed amount

is $70, the provider may bill you for the remaining $30.

A preferred provider may not balance bill you for covered

services.

Co-insurance

Co-payment

A fixed amount (for example, $15) you pay for a covered

health care service, usually when you receive the service.

The amount can vary by the type of covered health care

service.

Deductible

The amount you owe for

health care services your

health insurance or plan

covers before your health

insurance or plan begins

Jane pays

Her plan pays

to pay. For example, if

100%

0%

your deductible is $1000,

(See page 4 for a detailed example.)

your plan won¡¯t pay

anything until you¡¯ve met

your $1000 deductible for covered health care services

subject to the deductible. The deductible may not apply

to all services.

Your share of the costs

of a covered health care

service, calculated as a

percent (for example,

20%) of the allowed

amount for the service.

Jane pays

Her plan pays

You pay co-insurance

20%

80%

plus any deductibles (See page 4 for a detailed example.)

you owe. For example,

if the health insurance or plan¡¯s allowed amount for an

office visit is $100 and you¡¯ve met your deductible, your

co-insurance payment of 20% would be $20. The health

insurance or plan pays the rest of the allowed amount.

Durable Medical Equipment (DME)

Complications of Pregnancy

Emergency Room Care

Conditions due to pregnancy, labor and delivery that

require medical care to prevent serious harm to the health

of the mother or the fetus. Morning sickness and a nonemergency caesarean section aren¡¯t complications of

pregnancy.

Glossary of Health Coverage and Medical Terms

Equipment and supplies ordered by a health care provider

for everyday or extended use. Coverage for DME may

include: oxygen equipment, wheelchairs, crutches or

blood testing strips for diabetics.

Emergency Medical Condition

An illness, injury, symptom or condition so serious that a

reasonable person would seek care right away to avoid

severe harm.

Emergency Medical Transportation

Ambulance services for an emergency medical condition.

Emergency services you get in an emergency room.

Emergency Services

Evaluation of an emergency medical condition and

treatment to keep the condition from getting worse.

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146

Page 1 of 4

Excluded Services

Health care services that your health insurance or plan

doesn¡¯t pay for or cover.

Grievance

A complaint that you communicate to your health insurer

or plan.

Habilitation Services

Health care services that help a person keep, learn or

improve skills and functioning for daily living. Examples

include therapy for a child who isn¡¯t walking or talking at

the expected age. These services may include physical and

occupational therapy, speech-language pathology and

other services for people with disabilities in a variety of

inpatient and/or outpatient settings.

Health Insurance

A contract that requires your health insurer to pay some

or all of your health care costs in exchange for a

premium.

Home Health Care

Health care services a person receives at home.

Hospice Services

Services to provide comfort and support for persons in

the last stages of a terminal illness and their families.

Hospitalization

Care in a hospital that requires admission as an inpatient

and usually requires an overnight stay. An overnight stay

for observation could be outpatient care.

Hospital Outpatient Care

Care in a hospital that usually doesn¡¯t require an

overnight stay.

In-network Co-insurance

The percent (for example, 20%) you pay of the allowed

amount for covered health care services to providers who

contract with your health insurance or plan. In-network

co-insurance usually costs you less than out-of-network

co-insurance.

In-network Co-payment

A fixed amount (for example, $15) you pay for covered

health care services to providers who contract with your

health insurance or plan. In-network co-payments usually

are less than out-of-network co-payments.

Glossary of Health Coverage and Medical Terms

Medically Necessary

Health care services or supplies needed to prevent,

diagnose or treat an illness, injury, condition, disease or

its symptoms and that meet accepted standards of

medicine.

Network

The facilities, providers and suppliers your health insurer

or plan has contracted with to provide health care

services.

Non-Preferred Provider

A provider who doesn¡¯t have a contract with your health

insurer or plan to provide services to you. You¡¯ll pay

more to see a non-preferred provider. Check your policy

to see if you can go to all providers who have contracted

with your health insurance or plan, or if your health

insurance or plan has a ¡°tiered¡± network and you must

pay extra to see some providers.

Out-of-network Co-insurance

The percent (for example, 40%) you pay of the allowed

amount for covered health care services to providers who

do not contract with your health insurance or plan. Outof-network co-insurance usually costs you more than innetwork co-insurance.

Out-of-network Co-payment

A fixed amount (for example, $30) you pay for covered

health care services from providers who do not contract

with your health insurance or plan. Out-of-network copayments usually are more than in-network co-payments.

Out-of-Pocket Limit

The most you pay during a

policy period (usually a

year) before your health

insurance or plan begins to

pay 100% of the allowed

amount. This limit never

Jane pays

Her plan pays

includes your premium,

0%

100%

balance-billed charges or

(See page 4 for a detailed example.)

health care your health

insurance or plan doesn¡¯t cover. Some health insurance

or plans don¡¯t count all of your co-payments, deductibles,

co-insurance payments, out-of-network payments or

other expenses toward this limit.

Physician Services

Health care services a licensed medical physician (M.D. ¨C

Medical Doctor or D.O. ¨C Doctor of Osteopathic

Medicine) provides or coordinates.

Page 2 of 4

Plan

A benefit your employer, union or other group sponsor

provides to you to pay for your health care services.

Preauthorization

A decision by your health insurer or plan that a health

care service, treatment plan, prescription drug or durable

medical equipment is medically necessary. Sometimes

called prior authorization, prior approval or

precertification. Your health insurance or plan may

require preauthorization for certain services before you

receive them, except in an emergency. Preauthorization

isn¡¯t a promise your health insurance or plan will cover

the cost.

Preferred Provider

A provider who has a contract with your health insurer or

plan to provide services to you at a discount. Check your

policy to see if you can see all preferred providers or if

your health insurance or plan has a ¡°tiered¡± network and

you must pay extra to see some providers. Your health

insurance or plan may have preferred providers who are

also ¡°participating¡± providers. Participating providers

also contract with your health insurer or plan, but the

discount may not be as great, and you may have to pay

more.

Provider

A physician (M.D. ¨C Medical Doctor or D.O. ¨C Doctor

of Osteopathic Medicine), health care professional or

health care facility licensed, certified or accredited as

required by state law.

Reconstructive Surgery

Surgery and follow-up treatment needed to correct or

improve a part of the body because of birth defects,

accidents, injuries or medical conditions.

Rehabilitation Services

Health care services that help a person keep, get back or

improve skills and functioning for daily living that have

been lost or impaired because a person was sick, hurt or

disabled. These services may include physical and

occupational therapy, speech-language pathology and

psychiatric rehabilitation services in a variety of inpatient

and/or outpatient settings.

Skilled Nursing Care

Services from licensed nurses in your own home or in a

nursing home. Skilled care services are from technicians

and therapists in your own home or in a nursing home.

Specialist

The amount that must be paid for your health insurance

or plan. You and/or your employer usually pay it

monthly, quarterly or yearly.

A physician specialist focuses on a specific area of

medicine or a group of patients to diagnose, manage,

prevent or treat certain types of symptoms and

conditions. A non-physician specialist is a provider who

has more training in a specific area of health care.

Prescription Drug Coverage

UCR (Usual, Customary and Reasonable)

Premium

Health insurance or plan that helps pay for prescription

drugs and medications.

Drugs and medications that by law require a prescription.

The amount paid for a medical service in a geographic

area based on what providers in the area usually charge

for the same or similar medical service. The UCR

amount sometimes is used to determine the allowed

amount.

Primary Care Physician

Urgent Care

Prescription Drugs

A physician (M.D. ¨C Medical Doctor or D.O. ¨C Doctor

of Osteopathic Medicine) who directly provides or

coordinates a range of health care services for a patient.

Care for an illness, injury or condition serious enough

that a reasonable person would seek care right away, but

not so severe as to require emergency room care.

Primary Care Provider

A physician (M.D. ¨C Medical Doctor or D.O. ¨C Doctor

of Osteopathic Medicine), nurse practitioner, clinical

nurse specialist or physician assistant, as allowed under

state law, who provides, coordinates or helps a patient

access a range of health care services.

Glossary of Health Coverage and Medical Terms

Page 3 of 4

How You and Your Insurer Share Costs - Example

Jane¡¯s Plan Deductible: $1,500

Co-insurance: 20%

Out-of-Pocket Limit: $5,000

st

st

December 31

End of Coverage Period

January 1

Beginning of Coverage

Period

more

costs

Jane pays

100%

Her plan pays

0%

Jane hasn¡¯t reached her

$1,500 deductible yet

Her plan doesn¡¯t pay any of the costs.

Office visit costs: $125

Jane pays: $125

Her plan pays: $0

Glossary of Health Coverage and Medical Terms

more

costs

Jane pays

20%

Her plan pays

80%

Jane reaches her $1,500

deductible, co-insurance begins

Jane has seen a doctor several times and

paid $1,500 in total. Her plan pays some

of the costs for her next visit.

Office visit costs: $75

Jane pays: 20% of $75 = $15

Her plan pays: 80% of $75 = $60

Jane pays

0%

Her plan pays

100%

Jane reaches her $5,000

out-of-pocket limit

Jane has seen the doctor often and paid

$5,000 in total. Her plan pays the full

cost of her covered health care services

for the rest of the year.

Office visit costs: $200

Jane pays: $0

Her plan pays: $200

Page 4 of 4

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